Migrants and TB: Trapped in conflict of border control and health policies

Dr Gilles Cesari, The UnionPhoto credit: CNS

Bobby Ramakant - CNS
The 4th Union Asia Pacific Region Conference on Lung Health (APRC 2013) opened in Hanoi, Viet Nam, with a powerful and thought-provoking session on TB and migrants. There are scores of known structural drivers that put people at risk of TB such as poverty, but other less-spoken factors, such as immigration laws, International relations between countries, legal status of migrants, labour laws, and politics of borders where some countries deport expats who develop TB, need more attention too. According to International Organization for Migration
(IOM), there are 215 million international and 740 million internal
migrants. Migrants in many parts of the world are known to have reduced
access to TB diagnosis and treatment, affecting the global fight against
the disease. A range of policy measures have been taken at different
levels including global, yet implementation is indeed lacking in most
countries. The countries where migrants originate from, as well as the
countries receiving migrants, have the responsibility to establish
partnerships to ensure continuity of care.WHEN ARE IMMIGRANTS MORE LIKELY TO TEST POSITIVE FOR TB:BEFORE OR AFTER ENTERING THE DESTINATION?

Immigrants are less likely to enter UK with TB but more likely to develop TB after they enter UK, said Dr Richard Coker who divides his time between London School of Hygiene and Tropical Medicine (LSHTM) centre in Bangkok and Saw Swee Hock School of Public Health (SSHSPH) Singapore. Dr Coker said that in a study done on detecting TB in immigrants in 2004, it was found that 0.3% of asylum seekers had TB at port screening and of these only 1/4th had infectious disease. Number of TB cases detected through Heathrow airport in London was less than 0.5%. Dr Coker said that “Most TB occurs after they enter UK.” This exposes the realities of migrants in UK that continue to put them at a much heightened risk of developing active TB disease than general population.

“Evidence base to support TB screening of immigrants is weak. Screening tests for TB lack validity but screenings tests for HIV are reliable” added Dr Coker. He surely has put a serious question mark on the hypothesis behind aggressively pushing TB screening of immigrants – is it really helping control TB?

It does not make any financial justification too. Governments spend about 100 times more money on clamping immigration laws and border control than the current funding gap in global TB control. Asia Pacific Regional Director of International Union Against Tuberculosis and Lung Disease (The Union) Dr Gilles Cesari, rightly reminded the APRC 2013 delegates of the World TB Day theme of 2007: TB anywhere is TB everywhere.

4 OUT OF 5 OBJECTIVES OF STOP TB STRATEGY COMPROMISED

The needs and contexts of migrants are unique and TB care and control programmes need to take that into account in order to be more effective. Dr Gilles Cesari said that four out of five key objectives of the WHO Stop TB Strategy will continue to remain compromised, and cannot be realized optimally unless we take needs of migrants into account and tailor TB control interventions appropriately.

The five key objectives Dr Cesari was referring to of the WHO Stop TB Strategy are:

1. Achieve universal access to high quality diagnosis and patient-centred treatment2. Reduce the human suffering and socioeconomic burden associated with TB3. Protect the poor and vulnerable populations from TB, TB-HIV and MDR-TB4. Support development of new tools and enable their timely and effective use (this objective is not compromised by migrant issue)5. Protect and promote human rights in TB prevention, care and control

Except objective number 4, let us review if we can honestly realize the remaining four objectives of WHO Stop TB Strategy unless we take needs of migrants too into account in our ‘TB programming’? The absence of targeted TB prevention, control and surveillance
strategies for migrants is a barrier to reaching global TB elimination
targets, including the aspirational goals of 'Zero TB Deaths, Zero TB
Disease and Zero Suffering'. Let us all remember that most governments have recognized the WHO Stop TB Strategy and committed to align their national TB programmes in line with the global targets set by the Global Plan to Stop TB, and Millennium Development Goals (MDGs). How will we achieve these targets unless we recognize and include migrant population in all earnestness in our 'TB control programming' at all levels?

To understand unique contexts and needs of migrants, a session presenter classified them as follows: Internal migrants are individuals who move within the borders of a country, usually measured across regional, district or municipal boundaries, resulting in a change of usual place of residence. Labour migrants are individuals engaged in a remunerated or study activity in a state of which he or she is not a national including persons, legally admitted as a migrant for employment. Irregular migrants are individuals who enter a country often in search of employment, without the required documents or permits. Casual cross-border migrants and refugees are other groups of migrants. She advocated that governments apart from other measures, must consider giving a legal status to irregular migrants, at least for duration of TB treatment.

Another session presenter said that a significant number of migrants from Cambodia go to Malaysia and Thailand for work. The wages for less-skilled jobs in these nations are more than that in Cambodia. About 100,000 migrants were brought back to Cambodia through legal process. This is indeed tip of the iceberg. In countries they migrate to such as Malaysia and Thailand, it is very difficult for them to get social security that is enjoyed by other legal citizens. For example in Thailand their access to healthcare is limited, and their work and living conditions put them at risk of contracting TB and other health problems.

CONFLICT OF POLICIES: IMMIGRATION AND HEALTH

Immigration laws, border control and other policies need to become more sensitive and harmonious to public health and social justice. TB anywhere is TB everywhere, as Dr Cesari said. The evidence for aggressive TB screening at immigration points is weak, the public health rationale is against deporting TB patients to their home countries and in favour of supportive health policies for legal and illegal migrants, and forcing migrants with TB to go underground is clearly not what, any government, that upholds right to health, wants. Let us hope APRC 2013 will further 'push the envelope' in making governments review their own immigration policies to be more supportive of public health and social justice in context of migrants.